Relationship Information

Only enter the name of the responsible party of different than the patient.

Address/Phone

Address/Phone for the responsible party (if different from before)

Employer Information

If patient/responsible party is employed, please name their employer.

School Name

If patient/responsible party is a full-time student, please list the name of their school.

Name of Spouse/Partner

If patient/responsible party has a spouse/partner, please name them here.

Spouse/Partner Employer

If patient/responsible party has a spouse or partner, please list the employer of the spouse/partner here.

Emergency Contact*

Please name the patient's emergency contact here.

Emergency Contact - Relationship*

Please tell us the relationship of the patient's emergency contact.

Emergency Contact - Phone*

Please tell us the phone number of the patient's emergency contact.

Nearest Relative

Please tell us the patient's nearest relative not living with them.

Nearest Relative - Relationship

Please tell us the relationship of patient's nearest relative not living with them.

Nearest Relative - Phone

Please tell us the phone number of patient's nearest relative not living with them.

How did you hear about our office?*

Please help us by telling us how you discovered our practice.

If Friend / Co-Worker / Family, please tell us their name.

If Insurance Company, please name the company.

If Festival or Community Event, which one?

If Other, where?

Dental Insurance Information

Do you have dental insurance?*

Insurance Company

Insurance Phone Number

Policy Effective Date

Subscriber Name

Employer

SSN or Member ID

Birthdate

Group # / Policy #

Relationship

Do you have a secondary dental insurance?

Insurance Company

Secondary Insurance Phone Number

Policy Effective Date

Subscriber Name

Employer

SSN or Member ID

Birthdate

Group # / Policy #

Relationship

Medical Information

Are you under the care of a physician now?*

Physician Name

Physician Phone

Last Physical Exam

Do you currently have, or have you ever had any of the following?

Heart Failure*

Hepatitis*

Nervousness / Depression*

Heart Disease / Attack*

Liver Disease*

Psychiatric Treatment*

Chest Pain*

Epilepsy or Seizures*

Multiple Sclerosis*

High Blood Pressure*

Fainting / Dizzy Spells*

Diabetes*

Heart Murmur*

Cancer / Leukemia*

Thyroid Disease*

Mitral Valve Prolapse*

Chemotherapy*

HIV Positive*

Rheumatic Fever*

Glaucoma*

AIDS*

Heart Defects*

Emphysema*

Arthritis*

Scarlet Fever*

Asthma*

Pain in Jaw Joints*

Artificial Heart Valve*

Difficulties Breathing*

Loss of Appetite*

Heart Pacemaker*

Sinus Trouble*

Loss of Sleep*

Heart Surgery*

Severe Allergies / Hives*

Use a C-pap*

Artificial Joints / Prosthesis*

Yellow Jaundice*

Loud Snoring*

Anemia*

Drug Addiction*

Bruise Easily*

Stroke*

Hemophilia*

(Frequent) Cold Sores*

Kidney Disease*

Sickle Cell Disease*

Adverse reaction to local anesthetic (Novacaine)*

Latex Allergy*

Medication Allergies*

List any and all medications that you are knowingly allergic to, or have had an adverse reaction to.

Current Medications*

Please list ALL medications you are currently taking. If you are not taking any medications at this time, please type "none."

Are you pregnant or trying to get pregnant?*

Are you currently taking Birth Control Pills?*

Are you currently taking Blood Thinners?*

Do you smoke?*

Is there any other medical information not included above which we should be informed about?

Additional Medical Information

Because you answered "Yes" above, please tell us here.

Have you ever or do you currently receive Botox® Injections?

Type of Botox® treatment.

Please indicate the nature of your treatment.

Dental Information

Has the fear of discomfort kept you from regular dental visits?*

Are you satisfied with your past dentistry?*

Have you had any bad experiences in a dental office?*

Have you ever had Periodontal Therapy?*

Are you concerned that you may have bad breath?*

Do your gums bleed easily, feel tender or irritated?*

Are your teeth sensitive to hot, cold and/or sweets?*

Are there areas in your mouth where food sticks and/or gets caught?*

Are you self-conscious about the appearance of your teeth?*

Do your jaws often feel tired and/or sore?*

Do you experience excessive headaches and/or neck pain?*

Do you experience clicking or popping when opening/closing/chewing?*

Are you aware of yourself clenching or grinding your teeth?*

Have you ever had Orthodontic Treatment (Braces)?*

What prompted you to seek dental care at this time?*

Approximately how long has it been since your last dental examination & cleaning?*

What, if anything would you do to change the appearance of your teeth? (Check all that apply)

Whiter

Straighter

Longer

Shorter

Shaped Differently

I would not change anything

Consent

I acknowledge that all of the above information is accurate to the best of my knowledge. I authorize this office and its trained staff to take x-rays & other diagnostic aids needed to make proper diagnosis of my dental needs. I authorize this office and its trained staff to perform all forms of treatment, as is indicated. I understand the use of anesthetic agents will be used when indicated & that this embodies a certain risk. I give my permission to release medical/dental information as needed to process insurance claim forms or to receive proper treatment from other health providers.

Signature of Patient / Parent or Guardian*

Entering your name above constitutes your signature to proceed.

By entering my name above and checking this box, I consent to give this information.*

I consent.

Financial Agreement

FINANCIAL AGREEMENT

By checking the box below you acknowledge and understand that payment in full for all services is required at time of visit, unless prior arrangements have been made.

INSURANCE FILING

By checking the box below you acknowledge and understand that you (patient) are ultimately responsible for payment in full on your account, not the insurance company. We do file dental insurance claims as a courtesy to our patients. You understand that we can only make estimates regarding your insurance benefits based on the information provided by you and the insurance company. In the event your insurance company does not pay as much as expected, you understand that the remaining balance is due and payable immediately by you.

ASSIGNMENT OF INSURANCE BENEFITS

By checking the box below you hereby assign all insurance benefits directly to our office which are otherwise payable to you. You also hereby authorize the release of any information relating to any claims. You understand that you are financially responsible for charges not paid by this assignment.

I agree to all the terms listed above.*

Yes, I agree to all the terms listed above.

By checking this box you agree to all the terms listed above.

DELINQUENT ACCOUNTS

By checking the box below you acknowledge and understand that all delinquent accounts (30 days or older) are subject to reasonable service charges and/or legal interest rates.

COLLECTION PROCEEDINGS

By checking the box below you acknowledge and understand that in the event your account is turned over to a collection agency for non-payment or other delinquency, you will be responsible for payment of any and all reasonable collection costs and/or attorney fees, in addition to the balance owed. All accounts turned over to a collection agency forfeits any past special fees and/or discounts. Such special fees and/or discounts will be reversed and you will be responsible for payment of regular fee for procedures at the time of service.

FAILED APPOINTMENTS

Failed appointments are a significant contributor to rising heath care costs. By checking the box below you acknowledge and understand that your account will be assessed a usual and customary fee for any missed or changed appointment with less than a 24 hour notice.

I agree to all the terms listed above.*

Yes, I agree to all the terms listed above.

By checking this box you agree to all the terms listed above.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

CLICK HERE to read our Notice of Privacy Practices.
By checking the box below you acknowledge that you were provided a copy of this office’s Notice of Privacy Practices, and you also understand that you have a right to refuse to sign this acknowledgment. Additionally, as a recommended office of BestDentalCareAZ.com, we agree to periodic and random quality control assessments to ensure that we continue to meet their high expectations in patient care. Occasionally this includes speaking with an actual patient. By signing below you are providing our office your consent to give BestDentalCareAz.com your limited contact information (phone and email only) as part of their quality control procedures.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

CLICK HERE to read our Notice of Privacy Practices.
By checking the box below you acknowledge that you were provided a copy of this office’s Notice of Privacy Practices, and you also understand that you have a right to refuse to sign this acknowledgment.

I agree to all the terms listed above.*

Yes, I agree to all the terms listed above.

By checking this box you agree to all the terms listed above.

FOR MEDICARE ELIGIBLE PATIENTS ONLY

By checking the box below you acknowledge and understand that this office is a non-participating office with Medicare. You further understand that as a non-participating provider, this office will not submit insurance claims to Medicare on your behalf. You understand that neither Medicare’s fee limitations nor any other Medicare reimbursement regulations apply to services provided in this office.